2 Public health need and practice
There are 9.7 million people aged 65 and older in the UK and by 2020 one in five UK citizens will be aged 65 or older. Though many older people lead happy, well-balanced and independent lives the transition into later life can be affected by many different variables, including physical health, financial security, societal attitudes, geographical location, access to support and services and responsibility for the care of others (Age Concern England and Mental Health Foundation 2004).
Despite better health and increases in wealth over the last 50 years, there is evidence that many older people are becoming increasingly dissatisfied, lonelier and more depressed, many living with low levels of life satisfaction and wellbeing (Allen 2008). Forty per cent of older people attending GP surgeries, and 60% of those living in residential institutions are reported to have 'poor mental health' (UK Inquiry into Mental Health and Well-being in Later Life 2006). A decline in mental wellbeing should not be viewed as a natural and inevitable part of ageing and there is a need to raise both older people's and societal expectations for mental wellbeing in later life (Mental Health and Older People Forum 2008).
Five key factors affect the mental health and wellbeing of older people: discrimination (for example, by age or culture), participation in meaningful activity, relationships, physical health (including physical capability to undertake everyday tasks) and poverty (UK Inquiry into Mental Health and Well-being in Later Life 2006).
The Social Exclusion Unit reports that many older people continue to experience discrimination despite the establishment of the Commission for Equality and Human Rights (including age equality) and the National Service Framework for Older People, which aims to stop age discrimination in health and social care (DH 2001). Commissioning, service provision and regulatory processes still do not consistently reflect established national policy. Direct and indirect age discrimination is evident through reductions in service and investment for older people's mental health (Mental Health and Older People Forum 2008).
Isolation is a particular risk factor for older people from minority ethnic groups, those in rural areas and for people older than 75 who may be widowed or live alone (Office of the Deputy Prime Minister 2006). Social activities, social networks, keeping busy and 'getting out and about', good physical health and family contact are among the factors most frequently mentioned by older people as important to their mental wellbeing (Third Sector First 2005; Audit Commission 2004).
Health and social care services have an important role in promoting and maintaining physical activity, health and independence (DH 2005a, DH 2005b). There is a decline in physical activity with increased age which may be associated with lack of opportunities and lack of encouragement (UK Inquiry into Mental Health and Well-being in Later Life 2006). Exercise and physical activity can be tailored to an individual's needs and abilities, increasing access for older people with disabilities and mobility needs (British Heart Foundation 2007).
The maintenance of physical activity in later life is central to improving physical health. Regular exercise has beneficial effects on general health, mobility and independence, and is associated with a reduced risk of depression and related benefits for mental wellbeing, such as reduced anxiety and enhanced mood and self-esteem (DH 2005c). Physical health and mental health, in turn, also have an impact on older people's economic circumstances and on their ability to participate in society (Marmot et al. 2003).
Self determination and a level of independence have also been associated with health and wellbeing. Self determination, in daily life, means ensuring that people have as much choice as possible about personal routines and activities (for example, when they eat or sleep, get up, go out or spend time alone) (Personal Social Services Research Unit 2006). Recent guidance for residential care homes reports that the provision of meaningful daily activities can restore and improve the health and mental wellbeing of residents (College of Occupational Therapists and National Association for Providers of Activities for Older People 2007).
Government initiatives at local and national level all emphasise the need for local authorities, health and social care services to prioritise improvement in older people's services. Central to the success of these initiatives is the involvement of older people in service planning, particularly those groups whose health and wellbeing may be compromised by advanced age or disability (DH 2006). Reforms to home care in England in 2008 will give older people greater independence and the right to choose their own home-helps and personal carers through means-tested personal budgets (DH 2007).
Since 2000, local authorities have had discretionary power to promote social, economic and environmental wellbeing, and a duty to engage the local community (including older people) in community planning (Local Government Act 2000). Better Government for Older People is a UK-wide partnership in which older people are the key partners. It aims to ensure older people are engaged as citizens at all levels of decision making, and in shaping the development of strategies and services for an ageing population.
Partnerships for Older People Projects (POPP), led by the Department of Health, aim to shift resources and culture towards earlier and better targeted interventions for older people within community settings. The pilots deliver a range of interventions aimed at promoting independence for older people in line with local needs. For example, they provide better access to information and peer support for older people, provide health promotion activities to support healthy living, and provide low-level or simple services for older people such as help with shopping, household repairs etc. Early findings from POPP pilot sites have shown improved access for excluded groups and greater involvement of older people within steering groups, commissioning, recruitment, provision and evaluation.